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Recognising the transition between the stages of labour

 

In a proportion of the babies, the transition between the latent phase and the active phase of labour or that from the active phase of labour to the second stage of labour should have been acknowledged. Identifying such transitions enables maternity teams to perform the optimal fetal and maternal monitoring for the given stage of labour.

 

Situation

A first-time mother attended at 4 cm dilatation. She was considered not to be in labour and was offered a bath for analgesia. Just under 3 hours later, she had a desire to push and was fully dilated. The fetal heart was assessed once in the first stage of labour. During the second stage, the fetal heart was not auscultated every 5 minutes.

The baby was born in poor condition and underwent active therapeutic cooling. Grade III HIE was diagnosed.

Commentary

The transition between the latent phase to the established first stage of labour and then into the second stage was not identified; therefore, there was limited fetal monitoring. Had the fetal heart been auscultated in the first stage of labour and correctly in the second stage of labour, an abnormality may have been identified that could have led to the baby’s birth being expedited or anticipated allowing the relevant health professionals, such as the neonatal team, to be present at birth.

 

Situation

A mother attended with ruptured membranes and regular uterine activity. On examination, she was 3–4 cm dilated, so a plan was made to mobilise. She returned 1 hour later complaining of increased pains and three contractions every 10 minutes. The fetal heart was auscultated and the rate had risen but this was not acted upon. A plan was made to reassess in 1 hour. After 30 minutes, the contractions increased and she also reported backache. She was 5–6 cm dilated and the fetal heart was auscultated after examination and was found to be around 60 beats/minute. Help was summoned and a decision to deliver by caesarean section was made.

The baby was born 25 minutes after the detection of the fetal bradycardia. At caesarean section, there was evidence of placental abruption. The baby died later that day.

Commentary

A change in the mother’s perception of the pain she is experiencing may be an indicator of a change in the course of her labour and maternity teams need to be receptive to this.

 

Things you can do

Listening, acknowledging and reacting appropriately to what a mother is communicating should be central to the care provided to her. It may be necessary to bring forward an examination or fetal heart rate assessment, rather than sticking rigidly to a previous plan. The clinical situation and the risk status are continuously evolving during labour and healthcare professionals must be alive to such change.